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RECEIVED q,- Il4-We, OW- 2Z-6a &17 )
PRESS SHED PERMIT APPLICATION
OCT 2 0 2021 TOWN OF YARMOUTH
Yarmouth Building Department
B U1y 1146 Route 28
South Yarmouth, MA 02664
/�
(508) 398-2231 Ext. 1261
CONSTRUCTION ADDRESS: too P OW it we7 VI yy4914,7'n, , �/9 0 Z 1/-73
ASSESSOR'S INFORMATION:
v nOI_G C T4ap: Parcel:
OWNER: F12Ah14LI41¢14 PE TS V' £7 )ow Mt fl1Df /JL/ R� . n'3(1)1 ae15'o
N ME PRESENT ADDRESS TEL. II
CONTRACTOR:
NAME MAILING ADDRESS TEL.#
ritfesidential 0 Commercial Est.Cost of Construction$ 0 000 "(D°
Home Improvement Contractor Lie.# Construction Supervisor Lic.#
Workman's Compensation Insurance: (check one)
El I ant the homeowner C] I am the sole proprietor D 1 have Worker's Compensation Insurance
Insurance Company Name: Worker's Comp.Policy#
SHED INFORMATION
/[� / / , /
New ✓ Size L `c x W`'D x H I� Corner Lot: Yes V No r
Per Town of Yarmouth Zoning By-Law Sec 203.5 E:
Side and rear setbacks for accessory buildings less than 150 square feet and single stofy, shall be 6 feet in all districts, but
in no case built closer than 12 feet to any other building.
Replace existing* Size L x W x H
*The debris will be disposed of at
Location of Facility
I declare wider penalties of perjury that the statements herein contained are true and correct to the best of my knowledge and belief. I understand that any false answers)
will be just cause for denial or revocation of my license and for prosecution under M.G.L.Ch.263.Section I.
A licant's Signature:
iDate:
Owners Signature(or attachment) Date: /O /404/
Approved By:—_-_ _---- Date: Cl 14— 1 —.__.
Building Offici ( csignee) EMt ADDRESS:
Zoning District:
Historical District: 1 Yes No Flood Plain Zone: . ' Yes No
Water Resource Protection District: Within 100 ft.of Wetlands:*,w::
LI Yes i.1 No ri Yes _ No
***Note:Conservation review required if within 100 ft.of Wetlands
9/13
�.\ The Commonwealth of Massachusetts
Department of Industrial Accidents
1 i 1 Congress Street, Suite 100
�, Boston, MA 02114-2017
..'y www.mass aov/dia
Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers.
TO BE FILED WITH THE PERMITTING AUTHORITY.
Applicant Information Please Print Legibly
Name (Business/Organization/Individual): Fg tw'kL/J of-rl'I LA Ji T ilb CGktvA r L .-7-i7e" 7 `r)
Address: 3`) -END)6 i Manicr!4L 0i—, 5.610114 Vo®gmeu7r4, 'lit) oz 64
City/State/Zip: S$N,yed b), /14A a2"p hone#: c1 V 39q 09''0 •
Are you an employer?Check the appropriate box: Type of project(required):
I. I am a employer with employees(full and/or part-time).* ' 7. E/New construction
2. am a sole proprietor or partnership and have no employees working for me in 8. ❑ Remodeling
any capacity.[No workers'comp. insurance required.]
3. I am a homeowner doingall work myself t 9. [ Demolition
❑ y [No workers'comp. insurance required.]
r,�, 10 ❑ Building addition
4.t-l�'am a homeowner and will be hiring contractors to conduct all work on my property. I will
ensure that all contractors either have workers'compensation insurance or are sole 11.[/Electrical repairs or additions
proprietors with no employees.
12.❑PIumbing repairs or additions
5.❑I am a general contractor and I have hired the sub-contractors listed on the attached sheet. 13.El Roof repairs
These sub-contractors have employees and have workers'comp.insurance.$
14.El Other
6.❑We are a corporation and its officers have exercised their right of exemption per MGL c.
152,§1(4),and we have no employees.[No workers'comp.insurance required.]
*Any applicant that checks box#I must also fill out the section below showing their workers'compensation policy information.
t Homeowners who submit this affidavit indicating they are doing all work and then hire outside contractors must submit a new affidavit indicating such.
$Contractors that check this box must attached an additional sheet showing the name of the sub-contractors and state whether or not those entities have
employees. If the sub-contractors have employees,they must provide their workers'comp.policy number.
I am an employer that is providing workers'compensation insurance for my employees. Below is the policy and job site
information.
Insurance Company Name:
Policy#or Self-ins.Lic.#: Expiration Date:
Job Site Address: City/State/Zip:
Attach a copy of the workers' compensation policy declaration page(showing the policy number and expiration date).
Failure to secure coverage as required under MGL c. 152, §25A is a criminal violation punishable by a fine up to $1,500.00
and/or one-year imprisonment, as well as civil penalties in the form of a STOP WORK ORDER and a fine of up to$250.00 a
day against the violator. A copy of this statement may be forwarded to the Office of Investigations of the DIA for insurance
coverage verification.
I do hereby cer ' under the pains and penalties of perjury that the information provided above is true and correct.
,Signature: � ��� Date: /9li/1-
Phone#:
Official use only. Do not write in this area, to be completed by city or town official.
City or Town: Permit/License#
Issuing Authority(circle one):
1. Board of Health 2. Building Department 3. City/Town Clerk 4. Electrical Inspector 5. Plumbing Inspector
6. Other
Contact Person: Phone#:
T. .
PLOT PLAN
,
FOR LOT #
Indicate location of garage or accessory building
Additions with dashed lines
Sewerage disposal (cesspool) ED
Well ix
I I
— — — I C lot...4': :. .....ft. rear) ; I
till-
Abuttor's 4 , — — — _
Name
Lote
—I. �' �+ ! + Namur
i� 11 I Lot if
REAR WARD r '0'
If this is a r.
orner lot, .. .. `. .,.€ . — ` If this
rite in name corner
v
of street. I write i
l name of
Q. other
i0��/ 8 street.
in, _ r _ C ,b
4 I i 4.
. SIDE YARD
HOUSE SIDE 'YARD •
2 ,,,,,,,:: , .
, •
? , .
, :
I
`, •: , .
!- : SET BACK
:
•
41
ft.
I41
I ,9
I
a
(lot 1 ); 1 ' ft. frontage)
/ p Uu)0Izs " ''v � AI \J rn61,7d
/ (NAME OF STREET)
Information
Supplied by
r
[ARK NORTH POINT
Information and Instructions
mienchisittts General Laws chapter 152 requires all eu 1oyirs to provide workers'compensation fix their employees
Pursuant b this statute,an eaepleyett is defined as"...every person is the service of another under any contract orbit*,
express or implied,oral or written."
An tyke is defined to"an individual,peetanbip,aasociatlo*,cosmetics at other legal entity,or any two or mote
of the Ongoing engaged he a Joint enterprise,and including the bpi cep reeenoafre+a of a deceased employer,or the
receiver or beatoe of an faditidwi,partnership,sasociedoe or other legal entity,employing employees. However the
owner of a dwelling house having not mon than three apartmento and whit resides dare*or the occupied oldie
dwelling lame of another who empl ys pasties to der maintenance,coneauctlos or repair work on suck dwelling home
or as the pounds or banding appurtenant thereto shall not because of suck employment be deserted to be an employer."
MMGL chapter 132,I25C(6)ale ttabe that"every state er Neal Uteri(area the/withheld the issuance at
renewal at s gems sr permit to operate a budges se to aaa.trael tugdhtge is the cumeswaaltk Ow any
wawa tube has net predneed aseeptakls easiest*of eemplesae with the Iareranee senses regwted."
Additionally.WA chapter 132,f25C(7)stets"Neither the coaaaoawatlth nor any of its political aablitidaes shall
eater Ines any contract fist the perineum*of public wadi until acceptable evidence of compliance with the ingenues
require:male of this claoptsr haw been presented to the contract*authority."
Applies**
Pleas fill od the wearers'oattpawtlon affidavit completely,by checking the boxes that apply to your situating sod,it
neceasery,supply nui.oaetractae(e)nesne(s)r adihuw(en)and phone o®ber(e)along with their casaltieste(s)of
ineutssae. Limited Llaiillty Commies(LLC)or Limited Liability Partnership(LLP)with me employes other than the
nimbi*a perttner,as not rewired to carry melons'compeasdar imunmds. It n L.L.0 or LL.t doss have
employees,a policy is required. Be advised that this at3lldavit may be suheoitted to the Deportment of Induatrd
Amidst*for coafigaertios of ineenece coverage. Abe be refs to sip and date the affidavit. The affidavit should
be refused re the city a laws rhea the*Ogaden fie the remit or Limas is befog sgeeeled,not the Demitasse of
• industrial Accident& Should you have any condom reseeding the lawn or ilium are requited r obtain a workout'
cam policy,pits call the Deperunat at the numbs limed below. Sslfineund eampawfea should eater their
sdlFimenwse names maim as the eppeo eisb lima
City er Town OAidab
Pieces be ewe that the affidavit Le ematp{eao and printed legibly. The Department has provided a spear at the barns
of the afldsvit fbr you to fill out La the sweat the Once of lsradptfoar has to contact you regarding the appellant
Please beam b fill in the permiklice +number which will be need as a r fast ce umber. In oddities.a•applicant
that mast sehadd mild M permWNnamm application is any given year,need only submit oar affidavit indicating teed
policy hdhrmweioa(if nseasny)and under"hob Site Address"the applicant should write"all faeitdaas le (city oe
town)."A copy of the affidavit thud has been of4Nlly st taped or meth*by the city or town may be provided t the
applieaed as proof dui a valid affidavit is as flit her Uwe mot*or Hama A new affidavit meet be filled out each
yen.When a borne owner or cheers le obtaining a license or permit not twisted to any bugloss ar annmernfi venture
(Le:a dos license or penult to boa leanee etc.)said person is►10T required se aosnpbe tide affidavit
The Ofils of lavesdptiose would lies to thank yew is advance fir your cooperatlos and should you have any quaetion&
please de net hesitate to give us a all.
Clta Depmeneat'a address.tdephome end(as araba
T st Commonwealth of Massachusetts
Department of Industrial Accidents
Mee of r..adpda..
600 Washington sheet
Boston,MA 02111
Td. #617-727-1900 at 106 or 1-877-MAssAFB
Revised t 1-22at6 Fax M 617-m-7749
wvwvw.nusu.[midis
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3 r`; Conservation Office
Town of Yarmouth
�.- 11_ 4
15E ; Conservation Commission
Building Permit Sign-off Application
Building Site Location: 50 Powers Lane, W. Yarmouth, MA 02673
Map # Lot(s)#
Property Owner: Franklin & Melanie Tseng Date filed: 1 1/16/2021
*Applicant: Franklin Tseng
Applicant Address: 37 Indian Memorial Drive, S. Yarmouth, MA 02664
Email: franklinlakeland@gmail.com Telephone:508 394-0940
Proposed Project Description:
We are building a 14'X 10'shed in the back yard of 50 Powers Lane, in W. Yarmouth, MA. It's within the required
setback from the property lines and distance from existing building. It's in Great Island Ocean Club. Becuase it's in a
flood zone, the Building Department says we must get a Conservation Clearance. We plan to use 4' Sonotubes at the 4
corners of the shed to tie it down.
Site Plan Title/Date: S- i-k- Oa L-1 I ///6/2-7
TO BE FILLED OUT BY CONSERVATION ADMINISTRATOR:
Does the proposed project require a permit?J7d/'?/t? 3 u r'—ec-z
Refer to: SE83- or DOA permit
Comments from Conservation Commission: Approved Conditionally Approved ) Rejected
C2+1y ..E— r iAr 3'liked sChrer.t.t. a C 'C
attizvi-e d1S it; Sa r ne 6 n ,/,,
SL'232 G� 5i 1.0_ Sec C 4,6 fir �' f�jCs ��/ ,
Conservation Commission Sign-off Signature: 2 Date:
All work-related debris shall be taken offsite or disposed in a legal upland location. At the end of each
day, the area shall be clean and no debris shall be in the Resource Area.
If work is permitted under an Order of Conditions, please arrange a pre-construction site visit with the
Conservation Administrator. At the time of site visit, the MassDEP File Number sign must be installed,
along with the erosion control/work-limit line. A copy of the Order of Conditions must remain on-site
during construction. Please refer to the Order of Conditions for further details.
•
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_------ BENCHMARK:
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EL=G.44- (NAVD 1988)
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.tx Well: MIW29 fre_re)&it 0-'IN T-S -Crifb"--'
3e Zane: 0-2'
a Watet level(5/I 5); 7-G4
istment: I.3' 6 WNER
,to Water I evel: 5.1 (EL=I-17)
20 40 G